HomeMy WebLinkAbout1403 Cypress Dr - Special Inspections/Combustion Safety - 01/20/2017City Of Community Development
Collins 281 N College Ave.
PO Box 580F6rt
Fort Collins, CO 80522
970.416.2740
970.224.6134 (fax)
fcgo v. com/development
Combustion Safety Test Compliance Form
Replacement of Natural Draft Appliances in Existing Houses
Address:
Approved Agency:
I hereby attest that I have performed the following Combustion Safety Test in accordance with
Fort Collins Combustion Safety Test Guide Version 5, February 2012.
Technician Name (print): Company 7 _P:l �,IA_.,,
Technician Signature: Date
Appliance Tested: t/t/
Appliance Replaced: �lQ1rw'li
Worst Case Conditions:
Spillage Duration (in seconds): Carbon Monoxide (parts per million):
Pass Fail Date Tested: —2D —�
Natural Conditions:
Spillage Duration (in seconds):-_65;L Carbon Monoxide (parts per million):
Pass Fail Date Tested: ` 2
(Failed tes requires corrections until test passes under Natural Conditions)
Technician's recommendati o correct tested appliance failure:
Failed Worst Case Conditions:
I certify that I am the legal owner of the above
has failed a Combustion Safety Test under wo
combustion appliance safety information
Owner's Name (print)
Owner's Signature
CST: renlacemen-f/natural-draft/4.25.12
6 erty and hereby acknowledge that my appliance
conditions. I acknowledge that I have received a
Date